[104-10222-10032.pdf — page 31]
SECRET# EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE AND QUESTIONNAIREPRINT NAME (Pseudonym)TICINOGEN, Edward 0.## WITHMOLOINS EXEMPTIONSINSTRUCTIONS1.  NUNRER OF EARSTIOONS... Do not claim more than the correct number of exemptions. However, if you expect to ove more income tax for the year then will be withheld if you claim every exemption to which you are entitled, you may increase the withholding by claiming a smaller number of exemptions.2.  CHANGES IN KAENGTIONS. You may file a new certificate at any time at the number of your exemp?inns INCREASES.You must file a new certificate within 10 days if the number of exemptions previously claimed by you URREASKS for any of the following reasons:(a) Your wife (or husband) for whom you have been claiming exemption is divorced divorce or legally separated, or claims her (or his) own exemption on a separate certificate.(b) The support of a dependent for whom you claimed exemption is taken over by someone else, so that you no longer expect to furnish more than half the support for the year.(e) You find that a dependent for whom you claimed exemption will receive $600 or more of income of his own during the year (except your child who is a student or who is under 19 years of age).OTHER DECREASES in exemption, such as the death of a wife or a dependent, do not affect your withholding until the next year, but require the filing of a new certificato by December 1 of the year in which they occur.For further information about changes in exemption status rosulting from marriage, divorce, legal separa.tion, birth, death, new dependents, multiple-support agreements, old age, blindness, etc., consult your local District Director of Internal Revenue of your employer.3.  DEFENDENTS.: To qualify as your dependent (line 4 below), a person (s) must receive more than one-half of his or her support from you for the year, and (b) must have less than $500 gross mume during the year (except your child who is a student or who is under 19 years of age), ag and (c) must not be claimed as an exempe tion by such person's husband or wifs, and (d) must be • citizen or resident of the United States or a resi. dent of Canada, Mexico, the Republic of Faneme of the Canal Zone, and (e) must (1) have your home es his principal residence and be a member of your household for the entire year, or (2) be related to you as follows:Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, son in-law, or daughter-in-law;Your father, mother, grandparent, stepfather, stop. mother, father-in-law, or mother-in-tow:Your rother, sister, stepbrother, stepsister. er, half brother, half sister, brother-in-law, or sister-in-law:Your uncle, aunt, nephew, or niece (but only if related by blood).4.  PENALTIES...Penalties aro Imposed for willfully supplying falso information or willful failure to sup. ply information which would reduce the withholding exemption.1. If SINGLE, and you claim an exemption, write the figure "1"2. If MARRIED, one exemption each for husband and wife if not claimed on another certificate.(a) If you claim both of these exemptions, write the figure "2"(b) If you claim one of these exemptions, write the figure "1"(c) If you claim neither of these exemptions, write "0"}3. Exemptions for age and blindness (applicable only to you and your wife but not to dependents):(a) If you or your wife will be 65 years of age or older at the end of the year, and you claim this exemption, write the figure "1"; if both will be 65 or older, and you claim both of these exemptions, write the figure "2".(b) If you or your wife are blind, and you claim this exemption, write the figure "1"; if both are blind, and you claim both of these exemptions, write the figure "2"4. If you claim exemptions for one or more dependents, write the number of such exemptions. (Do not claim, exemption for a dependent unless you are qualified under instruction 3 above.)5. Add the number of exemptions which you have claimed above and write the total.235| INDICATE SOURCES OF INCOME |                      || -------------------------- | -------------------- || ![photo description]       | ![photo description] || ![photo description]       | ![photo description] || SALES DITHHELD FROM PROVE COVER        || -------------------------------------- || INDICATE VPELS) OF TALES AND AMOUNTIS) || INDICATE COVER PAY PERIO               || SOURCES COME || ------------ || U.S. FAXES   || DICATE HOW MUCH  || ---------------- || WITHHELO PER PAY || FOREICI TAXES    || PER VAAR || -------- || 3        || 3        |DECLARATION OF ESTIMATES COME TAX## CERTIFICATIONI CERTIFY that the number of withholding exemptions claimed on this form does not exceed the number to which I am entitled, and that the information relative to sources of income shown hereon is correct.DATESIGNED (Proudonya)313SECRET(30)